BACKGROUND: Cervical cancer screening guidelines for women aged ≥30 years allow for co-testing or primary cytology testing. Our objective was to determine the test characteristics and costs associated with Cytology, HPV and Co-testing screening strategies. MAIN METHODS: Retrospective cohort study of women undergoing cervical cancer screening with both cytology and HPV (Hybrid Capture 2) testing from 2004 to 2010 in an integrated health system. The electronic health record was used to identify women aged ≥30 years who had cotesting. Unsatisfactory or unavailable test results and incorrectly ordered tests were excluded. The main outcome was biopsy-proven cervical intraepithelial neoplasia grade 3 or higher (CIN3+). KEY RESULTS: The final cohort consisted of 99,549 women. Subjects were mostly white (78.4 %), married (70.7 %), never smokers (61.3 %) and with private insurance (86.1 %). Overall, 5121 (5.1 %) tested positive for HPV and 6115 (6.1 %) had cytology ≥ ASCUS; 1681 had both and underwent colposcopy and 310 (0.3 %) had CIN3+. Sensitivity for CIN3+ was 91.9 % for Primary Cytology, 99.4 % for Co-testing, and 94.8 % for Primary HPV; specificity was 97.3 % for Co-testing and Primary Cytology and 97.9 % for Primary HPV. Over a 3-year screening interval, Primary HPV detected more cases of CIN3+ and was less expensive than Primary Cytology. Co-testing detected 14 more cases of CIN3+ than Primary HPV, but required an additional 100,277 cytology tests and 566 colposcopies at an added cost of $2.38 million, or $170,096 per additional case detected. CONCLUSIONS: Primary HPV was more effective and less expensive than Primary Cytology. Primary HPV screening appears to represent a cost-effective alternative to Co-testing.

This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.

Context Research has been scarce on health professionals’ knowledge about guidelines regulating service dogs in a clinical setting. Gaining insight into health professionals’ understanding of Americans with Disabilities Act (ADA) regulations concerning service dogs is critical for navigating compliance and reducing risk. Misinformation about service dogs could influence decisions affecting policy and care, leading to poor treatment and suboptimal health outcomes for patients with service animals. Objectives To assess health professionals’ knowledge about ADA regulations and beliefs about workplace protocols and training related to service dogs. Methods The study used snowball sampling to distribute surveys to health professionals from around the United States. Initial outreach occurred using mailing lists, investigators’ personal networks, and social media. The survey contained 24 items. True and false questions were used to test ADA knowledge and then coded as correct or incorrect. Most closed-end questions were measured on a 5-point Likert scale using frequencies and descriptive statistics. A one-way analysis of variance (ANOVA) was conducted to test whether variables, such as encounters to service dogs, affected knowledge of ADA requirements. Results The survey was completed by 441 health professionals from around the country. Most (234; 53.1%) worked in a hospital and came from a range of professional backgrounds (nurses, 155 [35.2%]; physicians, 71 [16.1%]). While nearly three-quarters (318 [73.1%]) of participants said their workplace had a policy on service animals, 113 (34.9%) of those said they were unfamiliar with the policy and 236 (54.5%) said they had not received adequate training on the topic. Most participants did not know basic ADA policy requirements related to service dogs. Only those who were extremely familiar with policy (F=4.613; p=0.001) and those who strongly agreed that they knew the differences between service dogs and other classes of animals (F=5.906; p=0.000) scored higher on the knowledge test than those who disagreed. Conclusions Our results suggest that increased familiarity and training leads to higher knowledge about service dogs and ADA policy. Health professionals need additional education on ADA service dog regulations and hospital policy in order to minimize risk and ensure patients with service dogs receive optimal care.

Our results suggest that 1st- and 2nd-year students can be successfully integrated into clinical settings while maintaining patient satisfaction and perceived value of the care they receive.